(Radiographics. 2001;21:E1-e1.)
© RSNA, 2001
Interventional Musculoskeletal Procedures1
Afshin Gangi, MD, PhD,
Stephane Guth, MD,
Jean-Louis Dietemann, MD and
Catherine Roy, MD
1 From the Department of Radiology B, University Louis Pasteur, University Hospital of Strasbourg, 1 Place de l'Hôpital, BP 426 - 67091 Strasbourg, France. Received September 10, 2000; accepted November 9. Address correspondence to A.G. (e-mail: gangi@rad6.u-strasbg.fr)
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Abstract
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Percutaneous interventional procedures for the musculoskeletal system are demonstrated and explained by means of a hypertext-based teaching file. The authors provide an overview of different procedures including musculoskeletal biopsy, percutaneous periradicular infiltration, diskography, percutaneous cementoplasty, percutaneous treatment of disk herniation, and percutaneous treatment of osteoid osteoma. The procedures are demonstrated with detailed illustration of materials used and computed tomographic and fluoroscopic images. The authors guide the user through each step of the procedures, with case studies that include indications, techniques, complications, and results.
Index Terms: Bone neoplasms, diagnosis, 40.312, 40.32, 40.33 • Bones, biopsy, 40.1261 • Bones, diseases, 40. 312, 40.20, 40.32 • Bones, surgery, 40.1261, 40.1267 • Computed tomography (CT), guidance, 30.1211, 40.1211 • Fluoroscopy • Osteoporosis, 40.56 • Spinal cord, neoplasms, 30.32, 30.33 • Spine, biopsy, 30.1261 • Spine, diseases, 30.25, 30.32, 30.33 • Spine, fixation devices, 30.1267 • Spine, interventional procedures, 30.1261, 30.1267 • Spine, intervertebral disks, 30.25, 30.783 • Spine, radiography, 30.123
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Biopsies of the Musculoskeletal System
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Introduction
Histopathologic and bacteriologic studies are often needed in musculoskeletal lesions to establish a definitive diagnosis. In such cases, percutaneous musculoskeletal biopsy (PMSB) has become a routine procedure. Advantages of PMSB compared with surgical biopsy include the following:
- No weakening of bone structures through surgical removal. This is particularly true in weight-bearing bones and in children, thus avoiding immobilization or osteosynthesis.
- No limitation of activity.
- No or minimal soft-tissue injury.
- No extensive hospitalization; procedure done on an outpatient basis.
- No general anesthesia; the PMSB can be easily performed under local anesthesia and neuroleptanalgesia.
- Minimal recovery time.
- No scars.
- Lower cost.
Indications and Contraindications
Indications
Percutaneous bone biopsy is performed whenever pathologic, bacteriologic, or biologic examination is required for diagnosis or treatment. The major indications are the following:
- Primary or secondary bone tumors
- Osteitis
- Septic arthritis, diskitis
Contraindications
The expected results of biopsy should be significant compared with the risks of the procedure. Careful review of imaging findings and of previous studies should assist the radiologist in avoiding unnecessary biopsies. Well-known contraindications are the following:
- Bleeding diatheses
- Biopsies of inaccessible sites (odontoid process, anterior arch of C1)
- Soft-tissue infection
Technique
Material
- Sterile drapes, tampons
- 22-gauge needle, scalpel (Fig 1)
- Surgical hammer (may be required)
- Biopsy needle (drilling device may be required) (Figs 2–4):
- 2-mm-diameter hand drill
- Or 14-gauge Bonopty penetration set (RADI Medical Systems, Uppsala, Sweden)
- Or 14-gauge bone Ostycut biopsy needle (Ostycut; Angiomed/Bard, Karlsruhe, Germany)
- Or 8-gauge trephine needle (Laredo type)
- Iodine, 1% lidocaine
Dual Guidance
Percutaneous musculoskeletal biopsy, like other interventional procedures, is usually performed with a single imaging technique: fluoroscopy or computed tomography (CT), each of which has advantages and drawbacks. Fluoroscopy offers multiple planes and direct imaging, with the disadvantages of poor soft-tissue contrast and nonnegligible radiation exposure for both patient and operator. CT is well-suited for precise interventional needle guidance because it provides good visualization of bone and surrounding soft tissues. It also avoids damage to adjacent vascular, neurologic, and visceral structures. The disadvantages of this method are the single plane and delayed imaging.
To address these concerns on a routine basis, a combination of CT and fluoroscopy for interventional procedures has been recommended (Fig 5). For fluoroscopy, a mobile C-arm is used, positioned in front of the CT gantry. With a rotating fluoroscope and CT, the structure to be punctured can be visualized three dimensionally and with exact differentiation of anatomic structures, which in many cases is not possible with fluoroscopy alone. Two mobile monitors are placed in front of the physician, displaying the last stored image and the fluoroscopic image. The operator can switch from CT to fluoroscopy and vice versa at any time.
In percutaneous biopsy, the intervention begins with CT and is continued with fluoroscopy. Fluoroscopy is associated with CT whenever drilling is necessary.
Pathway
A CT scan is performed to localize the lesion precisely. The entry point and the pathway (Fig 6) are determined with CT, avoiding nerve, vascular, and visceral structures.
- For peripheral long-bone biopsy, the approach has to be orthogonal to the bone cortex. This approach angle avoids slippage with the tip of the needle. For minimizing tissue lesions during pass through as much as possible, the shortest path should be chosen. The approach must avoid nerve, vascular, visceral, and tendinous structures and, if possible, muscular and, if not required, articular structures.
- For flat bones such as scapula, ribs, sternum, and skull we use an oblique approach angle of 30°-60°. This angle is a compromise. The tangential approach is preferred to avoid damage to underlying structures, whereas the orthogonal angle avoids slippage with the tip of the needle.
- For the pelvic girdle, we use a posterior approach, avoiding the sacral canal and nerves.
- For vertebral body biopsy, different approach routes can be selected depending on vertebral level (Figs 7–11): the anterior route for cervical level, the transpedicular and intercostovertebral route for the thoracic level, the posterolateral and transpedicular route for the lumbar level. For the neural posterior arch, we use a tangential approach to avoid damaging underlying neural structures.
Anesthesia and Bone Puncture
Bone biopsy is usually performed with the patient under local anesthesia (Fig 12). Neuroleptanalgesia may be necessary for painful lesions. General anesthesia is used only in children. The procedure is carried out under strict sterility. The skin, subcutaneous layers, muscles, and periosteum are infiltrated with anesthetic (1% lidocaine) with a 22-gauge needle (Fig 13). The position of the 22-gauge needle is checked with fluoroscopy and CT. For bone puncture, the biopsy needle is inserted safely under CT guidance. Fluoroscopy is used in conjunction with CT whenever drilling is necessary. Cortical perforation may require the aid of a surgical hammer (Fig 14).
Biopsy Needle and Bone Penetration
For peripheral bone biopsy:
- Subperiosteal or cortical lesions without ossification are directly punctured with a 14-gauge needle.
- In cases of mild ossification or a small cortex surrounding the lesion, we use a 14-gauge Ostycut bone biopsy needle and penetration is performed with a surgical hammer.
- In cases of mild condensation and for primary tumors or lymphoma, we use an 8-gauge trephine needle (Laredo type).
- In cases of dense ossification or dense cortical bone surrounding the lesion, drilling is necessary. In these cases, we use a 2-mm-diameter hand drill or a 14-gauge Bonopty penetration set. For vertebral body biopsies (Fig 15):
- We use an Ostycut bone biopsy needle, and penetration is carried out with a surgical hammer. We use a 14-gauge needle at the cervical, thoracic, and lumbar levels.
- In cases of mild condensation and for primary tumors or lymphoma we use an 8-gauge trephine needle (Laredo type).
- In cases of dense ossification surrounding the lesion, drilling is necessary. In these cases, we use a 2-mm-diameter hand drill or a 14-gauge Bonopty penetration set. For soft-tissue biopsies:
- True-cut 14- to 16-gauge needles are used (Temno; Allegiance Sante S.A., Maurepas, France)
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Figure 15a. Vertebral body biopsy. Drawings show (a) drilling with Bonopty penetration set, (b) Ostycut needle penetration performed with surgical hammer, and (c) drilling with trephine needle.
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Figure 15b. Vertebral body biopsy. Drawings show (a) drilling with Bonopty penetration set, (b) Ostycut needle penetration performed with surgical hammer, and (c) drilling with trephine needle.
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Figure 15c. Vertebral body biopsy. Drawings show (a) drilling with Bonopty penetration set, (b) Ostycut needle penetration performed with surgical hammer, and (c) drilling with trephine needle.
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Biopsy
CT images are repeated to confirm the correct placement of the needle tip (Fig 16). Sampling is then performed. For pathologic examination, the specimen is fixed in 10% formalin. Material is sent for histology. If bacteriologic analysis is necessary, the specimens are not fixed and are sent for culture.
Complications
Complications of PMSB are rare. Possible and reported complications include the following:
- The major complication is septic osteitis. To avoid this complication, strict sterility during the intervention is mandatory.
- Hematoma.
- Reflex sympathetic dystrophy.
- Neural and vascular injuries.
- Pneumothorax. Murphy et al (Murphy WA, Destouet JM, Gilula LA. Percutaneous skeletal biopsy: a procedure for radiologists. Radiology 1981; 139:545-549]), in a large review of 9,500 percutaneous skeletal biopsies, identified 22 complications (0.2%). They reported nine pneumothoraxes, three cases of menigitis, and five spinal cord injuries. Serious neurologic injury occurred in 0.08% of procedures. Death occurred in 0.02% of procedures. Only two complications were observed among our 180 patients. These consisted of paravertebral hematomas that resolved spontaneously. This low level of complications seems to be related to the systematic use of dual guidance, which provides precise and real-time control.
Data and Statistical Results
From 1987 to 1999, 180 percutaneous musculoskeletal biopsies were performed on an outpatient basis (Table 1). The patients (63% female, 37% male) ranged in age from 17 to 87 years (mean, 58.4 years). Only two complication were observed among our patients. These consisted of paravertebral hematomas that resolved spontaneously.
Specificity for diagnosis was 100%, sensitivity was 93.9%, positive predictive value was 100%, and negative predictive value was 87.5%.
Cases
Case 1. Osteolytic metastasis, with Ostycut needle used for biopsy (Fig 17).
Case 2. Lymphoma, transpedicular trephine biopsy (Fig 18).
Case 3. Diskitis, diskal biopsy (Fig 19).
Case 4. Osteitis of the femur, percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route (Fig 20).
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Figure 20a. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20b. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20c. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20d. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20e. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Case 5. Cervical vertebral biopsy via lateral approach. Diagnosis: eosinophilic granuloma (Fig 21).
Case 6. Osteolytic lesion of rib, percutaneous biopsy with Ostycut bone biopsy needle via oblique route. Diagnosis: myeloma (Fig 22).
Case 7. Osteolsclerotic lesion of the sternum, percutaneous biopsy with Ostycut bone biopsy needle via oblique route. Diagnosis: breast cancer metastasis (Fig 23).
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Figure 23a. Case 7. Breast cancer metastasis. Percutaneous biopsy with Ostycut bone biopsy needle via oblique route. (a) CT scan of osteosclerotic lesion and (b) CT guidance for biopsy.
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Figure 23b. Case 7. Breast cancer metastasis. Percutaneous biopsy with Ostycut bone biopsy needle via oblique route. (a) CT scan of osteosclerotic lesion and (b) CT guidance for biopsy.
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Case 8. Cervical vertebral biopsy via anterolateral approach. Diagnosis: myeloma (Fig 24).
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Diskography
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Introduction
Low back pain is one of the most common disorders; however, the etiology of low back remains one of the most complex problems. Conventional imaging modalities such as plain radiography, CT, and magnetic resonance (MR) imaging are effective and, in many cases, sufficient diagnostic modalities. These modalities are, however, only morphologic. Diskography with the "memory pain test" is the only method that permits physiopathologic and morphologic exploration of low back pain. Therefore, diskography has a useful but limited role in the exploration of low back pain.
Indications and Contraindications
Indications
- Clinical signs of radiculopathy with inconsistent, negative, or equivocal CT, MR imaging, or myelographic findings.
- Performed before percutaneous laser disk decompression (PLDD), to prove that a disk herniation is contained.
Contraindications
- Diskography is an invasive technique and must not be used as a screening tool.
- Nerve paralysis due to disk herniation.
- Hemorrhagic diathesis.
- Local infection of cutaneous, subcutaneous, or muscle layers.
Material
- 22-gauge needle, 12.5-20 cm long
- 18-gauge, 9.5-cm needle at lumbar level
- Local anesthesia with 1% lidocaine
- Contrast medium (Omnipaque 180)
- 5-mL syringe and sterile connecting tube
- Iodine, sterile drapes
Technique
Puncture
The procedure is started with sterile preparation of the skin with an aseptic (iodine). The subcutaneous layers and lumbar muscles are infiltrated with local anesthetic (1% lidocaine) with a 22-gauge 9-cm-long needle. The position of the needle is checked with fluoroscopy and CT (Fig 25).
- Cervical level: The patient is placed in the supine position, head slightly turned and in hyperextension. The entry point and pathway are determined with CT. After local anesthesia of the skin, a 22-gauge 9.5-12.5-cm spinal needle is placed via an anterolateral approach in the center of the disk under dual CT and fluoroscopic guidance. Under precise CT guidance, puncture of the carotid artery is avoided.
- Lumbar level: The patient is placed in the prone position. The entry point and pathway are determined with CT. The subcutaneous layers and lumbar muscles are infiltrated with local anesthetic (1% lidocaine) with a 22-gauge 9-cm-long needle. The tip of the 18-gauge needle is positioned to reach the articular process and its placement is checked with fluoroscopy and CT. The stylet of this needle is then removed and a 22-gauge 20-cm stylet is inserted into the 18-gauge needle. The tip of the 22-gauge spinal needle is placed in the center of the disk. The position of the needle is checked with fluoroscopy and CT.
Contrast Agent Injection and Memory Pain Test
We inject 1-2 mL of contrast agent at the lumbar level and 0.3-0.5 mL at the cervical level (Fig 26). The patient is asked to describe pain reproduction and radiation during injection. Memory pain is positive if injection reproduces the patient's leg or back pain.
Complications
Complications of diskography are rare. The major complication is septic diskitis. To prevent this complication, strict sterility during the intervention is mandatory. No complications were observed among our patients.
Cases
Case 1. Diskography at L4-L5 level; memory pain test negative (Fig 27).
Case 2. Diskography at cervical level (Fig 28).
Case 3. Diskography at L5-S1 level; memory pain test negative (Fig 29).
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Percutaneous Periradicular Steroid Injection
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Introduction
The lumbar portion of the spine causes pain, suffering, and disability more frequently than any other part of the body. In the past 20 years, the growing crisis of disability resulting from low back pain has led to the recognition that the problem cannot be solved by better or more frequent surgery. Some minimally invasive interventional procedures are available to relieve pain and to minimize the risk of disability. These procedures offer multiple possibilities for lumbosacral pain control associated, according to need, with conventional pain therapies. Nerve root inflammations seems to be responsible for low back pain and sciatica. Percutaneous periradicular infiltration (PPRI) is an injection of steroids and anesthetic into the epidural space at the level of the pathologic disk.
Principle
There is no clear single explanation as to why a disk rupture causes back pain or sciatica or both (Figs 30, 31). Some disk ruptures remain asymptomatic. The patient’s major complaint is usually pain. However, physical pressure on a peripheral nerve alone does not produce pain; it produces paresthesia. In examining this problem further, at the conclusion of routine laminectomy for herniated nucleus pulposus, MacNab (JA McCulloch, EE Transfeldt. MacNab's backache. 3rd ed. Philadelphia, Pa: Lippincott, Williams & Wilkins, 1997; 227-230) placed a Fogarty catheter beneath the emerging nerve root of a segment above the laminectomy level. When the patient regained consciousness and before being given any analgesics, the catheter was distended. It was found that although distention of the catheter beneath an involved, red, inflamed nerve root reproduced the sciatic pain, distention of the catheter beneath a normal nerve root produced paresthesia only. It is likely that there are neuromechanical factors involved in explaining the mechanism of symptom production in a herniated nucleus pulposus. Periradicular injection of long-acting steroids is an efficient therapy, probably because it decreases inflammation of the epidural space.
Indications
The major indications for PPRI are
- Treatment of acute low back pain of diskogenic origin (without nerve paralysis) resistant to conventional medical therapy.
- Postdiskectomy syndrome.
Technique
The procedure is performed on an outpatient basis. The patient is placed prone on the CT table. A CT scan of the affected level allows precise choice of needle pathway. For this procedure, we use only CT guidance.
Lumbar level. The patient is placed in prone position. The entry point and pathway are determined with CT. After local anesthesia of the skin, a 22-gauge spinal needle is placed under CT guidance via a posterior approach near the painful nerve root. In intracanalar infiltration, absence of cerebrospinal fluid (CSF) is verified by aspiration. Once the needle is in the epidural space (Fig 32), 1.5 mL of air is injected (Fig 33) to confirm the extradural position of the needle tip. Then 2-3 mL of a long-acting steroid solution (cortivazol, 3.75 mg is injected (Fig 34), pure or mixed with a solution of 0.5% lidocaine (2 mL). Under precise CT guidance, dural sac perforation is avoided. However, if the dura is perforated because of an adhesion of the dural sac to the ligamentum flavum or because of a mistaken maneuver, the needle must be pulled back slightly and checked by aspiration for CSF. If there is none, the corticosteroid solution is injected without anesthetic. During injection, the patient may experience a spontaneous recurrence of pain lasting a few seconds, brought on by dural stretch.
Cervical level. The patient is placed in the supine position, head slightly turned and in hyperextension. The entry point and the pathway are determined with CT. After local anesthesia of the skin, a 22-gauge spinal needle is placed near the painful nerve root via a lateral approach under CT guidance. Then 2-3 mL of cortivazol solution is injected. Under precise CT guidance, vertebral artery injury and intraarterial injection are avoided.
Complications
Complications of PPRI under CT guidance are rare:
- Meningitis with neurologic damage (quadriplegia, multiple cranial nerve palsies, nystagmus) has been described after epidural or intrathecal injection of steroids if strict sterility is not respected. With precise CT monitoring, accidental intrathecal injection can be avoided. Strict sterility during the intervention is mandatory.
- There is a risk of calcifications with use of triamcinolone hexacetonide as a long-acting steroid. We do not recommend use of this steroid.
- At the cervical level, vertebral artery injury and intraarterial injection have been described. This can be avoided with precise CT guidance.
Results
Over 6 years, 186 periradicular injections were performed under CT guidance. The short-term benefits of PPRI include good pain relief in 78% of extraforaminal herniations and in 65% of herniations in other locations. The long-term result was satisfactory (persistence of relief for at least 6 months) in PPRI of extraforaminal herniations only: 68% had good results 2 years after the PPRI (average of three injections). Strict sterile technique limits the risk of infection. With precise CT monitoring, accidental intrathecal injection can be avoided. We had no complications in our series.
Cases
Case 1. PPRI at lumbar level for disk herniation and leg pain (Fig 35).
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Figure 35a. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Figure 35b. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Figure 35c. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Figure 35d. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Case 2. PPRI at cervical level for disk herniation (Fig 36).
Case 3. PPRI at lumbar level for disk herniation and leg pain (Fig 37).
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Figure 37a. Case 3. PPRI at lumbar level for disk herniation and leg pain. (a) Needle is placed in epidural space under CT guidance for (b) gaseous epidurography and steroid injection. (c) Epidurography shows disk after procedure.
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Figure 37b. Case 3. PPRI at lumbar level for disk herniation and leg pain. (a) Needle is placed in epidural space under CT guidance for (b) gaseous epidurography and steroid injection. (c) Epidurography shows disk after procedure.
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Figure 37c. Case 3. PPRI at lumbar level for disk herniation and leg pain. (a) Needle is placed in epidural space under CT guidance for (b) gaseous epidurography and steroid injection. (c) Epidurography shows disk after procedure.
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Case 4. PPRI at cervical level for disk herniation (Fig 38).
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Abstract
Biopsies of the Musculoskeletal...
